Powerpoint: gall stone disease and related disorders
Content
GALL STONE DISEASE AND RELATED DISORDERS
STRUCTURE OF THE BILIARY SYSTEM Right andand left left hepatic ducts-ductsCHD at Right hepatic CHD 3-4 cm. outside the liver \ue000 Cystic duct joins CHDCBD CBD Cystic duct joins CHD\ue000 CBD4-54-5 cm. cm. length, passes down down CBDlength, passes behind the duodenum, near the head of the pancreas \ue000 CBDdrains via via the ampulla of CBDdrains the ampulla of Vater- D2 \ue000
STRUCTURE OF THE BILIARY SYSTEM Gall bladder lies lies in a depression in the in the Gall bladder in a depression undersurface of the right hepatic lobe
\ue000
CBD6 mm. in diameter CBD6 mm. in diameter
\ue000
Bile made by the down the Bile made by liver, the passes liver, passes down the biliary tract into the GB- stored, concentrated- active reabsorbtion of water
\ue000
FUNCTION OF THE BILIARY SYSTEM Lipid-rich foodfood- duodenum Lipid-rich duodenumpromotes promotessecretion secretion of CCK- contraction of the GB forcing bile into the duodenum Bile- emulsifying of of Bileemulsifying agent, agent,facilitates facilitateshydrolysis hydrolysis lipids by pancreatic lipases. reach duodenum (biliary tracttract IfIf bile bile fails failstoto reach duodenum (biliary obstruction), lipids are neither digested or absorbed resulting in the passage of loose foulsmelling fatty stools (steatorhhea)
FUNCTION OF THE BILIARY SYSTEM Fat-soluble vitamins Fat-soluble vitamins (A,D,E,K) (A,D,E,K) not not absorbed Lack of Lack of vit.K.vit.K.-inadequate inadequate prothrombine synthesis and hence defective clottingproblems if surgery is necessary
PATHOGENESIS OF GALLSTONE DISEASE Most gallstonesMost gallstones- cholesterol+bile cholesterol+bile pigment+calcium salts Small proportion Small proportion are are“pure” “pure” cholesterol stones Asia- most Asiamost gallstones-bile gallstones-bile pigment alone
PATHOGENESIS Mixed stonesMixed stones- combination combinationofof abnormalities of bile constituents, bile stasis and infection Pigment stonesPigment stones- excess excessbilirubin bilirubin secretion due to hemolytic disorders and infection
PATHOGENESIS Main factors: Main factors:
– Change Change in in concentration concentration of of bile bile constituents – Biliary stasis Biliary stasis – Infection Infection
PATHOGENESIS Bile salts maintain Bile salts and andlecithinlecithinmaintain cholesterol in a stable micelle formation An excess excess of relation An of cholesterol cholesterolinin relation to bile salts and lecithin is one of the main factors Cholesterol precipitation Cholesterol precipitation is is enhanced by biliary stasis and infection
EPIDEMIOLOGY OF GALLSTONES 10% of population probably 10% of the theadult adult population probably have gallstones Women are as often Women are affected affected4 times 4 times as often as men Pregnancy, obesity, Pregnancy, obesity,diabetis diabetisareare predisposing factors The typical said to be: The typical patient patientis is said to fair, be: fair, fat, fertile, female of fourty Poor fiber play a part Poor fiber diet dietmay may play a part
INVESTIGATIONS Exclude hematological Exclude hematological and andliver liver abnormalities Establish whether Establish whether gall gallstones stonesareare present in the GB or CBD Assess integrity duct andand Assess integrity ofofbile bile duct pancreatic duct
INVESTIGATIONS Hemolytic disorders: Hemolytic disorders: hereditary hereditary spherocytosis, thalassemia and sickle cell disease- pigment stones Liver function Liver function teststests-jaundice jaundice
Blood culturesBlood cultures- severe severeangiocholitis angiocholitis U&E for for pts vomiting U&E pts with withfrequent frequent vomiting or diarhhea
INVESTIGATIONS Ultrasound scanUltrasound scan- can canassess assess
– Presence Presence of of stones, stones, – Thickness Thickness of of GB GB wall wall (inflammation/fibrosis), – Duct Duct dilatation, dilatation, – Obstruction: Obstruction: stones, stones, tumor, tumor, parasites – Structure of liver, Structure of liver, pancreas, pancreas, spleen spleen
CT- ACUTE CHOLECYSTITIS
PLAIN ABDO X RAY
PLAIN ABDO X RAY
INVESTIGATIONS NON-JAUNDICED PATIENTS
Not necessary Not necessary preop. preop.investigations investigationsforfor duct stones IfIf in in doubtdoubt-peroperative peroperative cholangigraphy at cholecystectomy Cholangiography via Cholangiography via cystic cysticduct ductinto into the CBD- filling defects caused by stones or distorsion of the lower end of the CBD or obstruction
INVESTIGATIONS JAUNDICED PATIENTS History of History of transient transientjaundicejaundiceERCP or cholangio-RMN- plan the appropriate type of operation preoperatively Frank obstructive obstructive jaundiceFrank jaundicedistinguish between stone and cephalic pancreatic tumor
BIOCHEMICAL FEATURES OF OBSTRUCTIVE JAUNDICE
Conjugated hyperbilirubinemia Conjugated hyperbilirubinemia Elevation of Elevation of alkaline alkalinephosphatase phosphatase Minimal or or no thethe serum Minimal noelevation elevationof of serum transaminases Presence of thethe urine as as Presence of the thebilirubin bilirubinin in urine the conjugated bilirubin is water soluble Elevation in of cholesterol and and Elevation in the theserum serum of cholesterol bile acid levels
INVESTIGATIONS OBSTRUCTIVE JAUNDICE
USS of dilatation of the USS of the theabdomen: abdomen: dilatation of biliary the biliary ducts, stone lodged in the duct, cephalic pancreatic nodule, enlarged lymph nodes in the porta hepatis ERCP- diagnostic diagnostic and ERCPand therapeutic therapeuticprocedureprocedureendoscopic sphincterotomy releasing the stone, relieving the jaundice Percutaneous transhepatic Percutaneous transhepatic cholangiography cholangiography
ERCP
ERCPSPHYNCTEROTOMY STONE EXTRACTION
ERCP
CHOLANGIO MRI
CHRONIC CHOLECYSTITIS Intermittent cystic Intermittent cystic duct ductobstruction obstruction Typically, patients Typically, patients are areoverweight overweight female Chronic inflammationinflammation- thickened Chronic thickened and and shrunken GB Long history nausea, Long history of ofRH RHpain, pain, nausea, vomiting Pain exacerbated meals Pain exacerbated by byfatty fatty meals
CHRONIC CHOLECYSTITIS Symptoms are Symptoms are ill-defined: ill-defined:pain, pain, nausea, fatty food intolerance Signs: mild Signs: mild RH RHtenderness tenderness Differential dg Differential dg – – –
Peptic Peptic ulcer ulcer disease disease Urinary tract infection infection Urinary tract Irritable bowel disease disease Irritable bowel
CHRONIC CHOLECYSTITIS MANAGEMENT Cholecystectomy is Cholecystectomy is the thedefinitive definitive treatment
Classic or Classic or laparoscopic laparoscopic
CHRONIC CHOLECYSTITIS
CHRONIC CHOLECYSTITIS
CHRONIC CHOLECYSTITISLAPAROSCOPIC VIEW
LAPAROSCOPIC CHOLECYSTECTOMY
BILIARY COLIC Sudden and of of Sudden and complete completeobstruction obstruction the cystic duct by stone Severe pain, twists in in Severe pain, the thepatient patient twists agony until the pain resolves often precedes the the AA bout bout ofofvomiting vomiting often precedes end of the attack History of History of previous previoussimilar similarepisodes episodes Few positive local Few positive physical physicalfindingsfindingslocal tenderness, no fever
BILIARY COLIC MANAGEMENT Pain relief, abdomen Pain relief, USS USS ofofthethe abdomen Immediate cholecystectomy Immediate cholecystectomy oror put the patient on the waiting list Avoid fatty Avoid fatty foods foods
ACUTE CHOLECYSTITIS Surgical emergency Surgical emergency Biliary colic, Biliary colic, fever, fever,tachycardia tachycardia RH tenderness RH tenderness Palpable RH Palpable RH inflammatory inflammatorymass mass Clinical course Clinical course of ofacute acute cholecystitis is more prolonged than biliary colic
ACUTE CHOLECYSTITIS MANAGEMENT USS, CT: USS, CT: thickened thickened wall wall Oral intake Oral intake restricted restricted totofluids fluids IV fluids, antibiotics IV fluids, pain painkillers killersand and antibiotics Early cholecystectomy Early cholecystectomy For inflammatory For inflammatory massmassconservative treatment- elective cholecystectomy after 2-3 months
ACUTE CHOLECYSTITIS
GANGRENOUS CHOLECYSTITIS
Empyema of the gall bladder GB distended an an abscess of of GB distended with withpuspusabscess the GB Swinging pyrexia Swinging pyrexia Part of wall becomes necroticPart of the theGB GB wall becomes necroticperforation- biliary peritonitis Perforation is by by Perforation is usually usuallywalled walledoffoff omentum- localized abscess formation Sometimes- subphrenic Sometimessubphrenic abscess abscessoror generalized peritonitis Surgery without Surgery without delay delay
GALLSTONE ILEUS Uncommon complication Uncommon complication of ofchronic chronic cholecystitis GB becomes thethe GB becomes adherent adherenttoto duodenum, a stone ulcerating through the wall to form a fistula Fistula decompresses decompresses the Fistula the obstructed GB and allows stones to pass into the bowel and gas to enter the biliary tree
GALLSTONE ILEUS Diagnosis- plain gasgas intointo Diagnosisplain abdo abdoXrayXraythe biliary tree or fluid levels of the small bowel- biliary ileus radioopaque cancan IfIf obstructing obstructing stone stoneis is radioopaque be seen as an opacity in the RIF Operation is remove the the Operation is needed neededto to remove obstructing stone from the terminal ileum: enterotomy, extraction, enteroraphy
Biliary ileus Rigler’s triad offindings: findings: Rigler’s triad of small bowel obstruction; pneumobilia; and gallstone in right iliac fossa. Note the thethe biliary Note the gas gasin in biliary tree, and rounded opacity in the pelvis
CT of show air air CT of the theabdomen abdomen show in the gall bladder (red (red arrow) air in (blue (bluearrow) arrow) air in the theCBD CBD representing pneumobilia, the gallstone small the gallstone ininthe the small bowel lumen (yellow arrow) (yellow arrow) dilated and dilated and fluid-filled fluid-filledloops loops of small bowel from SBO (green arrow)
INTRA-OPERATIVE FINDING
TRANSVERSE ENTEROTOMY
STONE REMOVAL AND ENTERORAPHY
BILE DUCT STONES Nearly always Nearly always originated originatedininthethe GB and passed through the cystic duct Most stones enough to to Most stones are aresmall small enough pass out of the biliary system into the duodenum, resulting in biliary colic and transient jaundice
BILE DUCT STONES CBD is lower end end CBD is narrowest narrowestatatitsits lower and stones too large to pass out They tend at this pointpoint They tend totolodge lodge at this becomes AA stone stone here hereeither either becomes impacted- progressive jaundice or acts as a ball-valve- intermittent jaundice
BILE DUCT STONES Obstruction results Obstruction results in ingradual gradual dilatation of the biliary tree it does not not IfIf dilatation dilatation isislong longstanding standing it does regress even after removal of the obstruction- bile stasis- further stone formation Note that notnot distend whenwhen Note that GB GBdoes does distend there is an inflammatory fibrosis caused by gall stones
CLINICAL PRESENTATION BILE DUCT STONES
Obstructive jaundice Obstructive jaundice Asymptomatic duct Asymptomatic duct stones stones Acute pancreatitis Acute pancreatitis Ascending cholangitis Ascending cholangitis
OBSTRUCTIVE JAUNDICE Causes: Causes:
– Stones Stones in in the the CBD CBD – Carcinoma Carcinoma of of the the head head of ofthe the pancreas – Periampullary Periampullary tumors tumors – Benign Benign strictures strictures of of the the CBD CBD – Extrinsic bile duct duct obstruction obstruction Extrinsic bile – Intrahepatic Intrahepatic bile bile duct duct obstruction obstruction
ASYMPTOMATIC DUCT STONES Any patient stones maymay Any patient with withgall gall stones have duct stones Some surgeons Some surgeons do doat at cholecystectomy, routine cholangiography to exclude the presence of CBD stones Some surgeons if there are are Some surgeons do dothat that if there positive test of cholestasis or dilated CBD
Common bile duct stone (choledocholithiasis). The sensitivity of transabdominal ultrasonography for choledocholithiasis is approximately 75% in the presence of dilated ducts and 50% for nondilated ducts
Notice inside the catheter is a black and yellow striped guide wire, this guide wire stays in the common bile duct as the balloon catheter is manipulated. Notice the arrow pointing at a stone that was removed from the common bile duct by the balloon catheter. This stone will pass through the intestines and will be expelled.
ACUTE PANCREATITIS Stones near of Vater Stones near the theampulla ampulla of Vater may interfere with drainage of pancreatic enzymes onto the duodenum This induces into thethe This induces bile bilereflux reflux into Virsung duct- acute pancreatitis
ASCENDING CHOLANGITIS Bile stasis CBD duedue to chronic Bile stasis ininthe the CBD to chronic duct obstruction- predisposis to bacterial infection The infection to to The infection extends extendsproximally proximally involve the intrahepatic duct system Pain, swinging Pain, swinging pyrexia, pyrexia,jaundice jaundice Life-threatening conditionLife-threatening condition- acute acute suppurative cholangitis Urgent bile or or Urgent bile duct ductdrainage: drainage:surgery surgery endoscopic sphincterotomy
CARCINOMA OF THE GALL BLADDER Chronic iritation a long Chronic iritation by by stones stonesover over a long period is believed to predispose to adenocarcinoma of the gall bladder Rare condition, elderly Rare condition, found foundininthethe elderly Usually unexpected Usually unexpected finding findingatat cholecystectomy, incurable at the time of detection Presenting symptoms chronic Presenting symptoms similar similartoto chronic inflammatory gall bladder disease Jaundice may Jaundice may develop develop
MANAGEMENT OF GALLSTONE DISEASE Non-surgical treatment treatment Non-surgical
Surgical treatment Surgical treatment
NON-SURGICAL TREATMENT Chenodeoxycholic acid Chenodeoxycholic acid increases increases the bile salt pool and inhibits hepatic cholesterol secretion Long-term treatmentLong-term treatment- slow slow dissolution of cholesterol stones High-rate of High-rate of stone stonerecurrence recurrence Side-effects- diarrhea Side-effectsdiarrhea and andhepatic hepatic damage
SURGICAL TREATMENT Open or Open or laparoscopic laparoscopiccholecystectomy cholecystectomy Exploration of Exploration of CBDCBD-peroperative peroperative cholangiography Presence of stone Presence of CBD CBDstonestonestone extraction- T tube drainage (Kehr) T-tube cholangiography at at T-tube cholangiography after afterremoval removal 14-21 days postoperativelly
BILE DUCT DRAINAGE PROCEDURES Choledoco-duodenostomy Choledoco-duodenostomy Choledoco-jejunostomy Choledoco-jejunostomy Transduodenal sphyncteroplasty sphyncteroplasty Transduodenal Endoscopic sphyncterotomy Endoscopic sphyncterotomy
COMPLICATIONS OF BILIARY SURGERY Retained stone CBDendoscopic Retained stone ininthe the CBDendoscopic sphyncterotomy Biliary peritonitis leakageBiliary peritonitis due due totobile bile leakagelavage and drainage Bile duct Bile duct damagedamage-relaparotomyrelaparotomyreconstruction Hemorrhage- slipping Hemorrhageslipping knot knot from fromthe the stump of the cystic artery- hemostasis Ascending cholangitisAscending cholangitis- late latecomplication complication of choledocoduodenostomy
STRUCTURE OF THE BILIARY SYSTEM Right andand left left hepatic ducts-ductsCHD at Right hepatic CHD 3-4 cm. outside the liver \ue000 Cystic duct joins CHDCBD CBD Cystic duct joins CHD\ue000 CBD4-54-5 cm. cm. length, passes down down CBDlength, passes behind the duodenum, near the head of the pancreas \ue000 CBDdrains via via the ampulla of CBDdrains the ampulla of Vater- D2 \ue000
STRUCTURE OF THE BILIARY SYSTEM Gall bladder lies lies in a depression in the in the Gall bladder in a depression undersurface of the right hepatic lobe
\ue000
CBD6 mm. in diameter CBD6 mm. in diameter
\ue000
Bile made by the down the Bile made by liver, the passes liver, passes down the biliary tract into the GB- stored, concentrated- active reabsorbtion of water
\ue000
FUNCTION OF THE BILIARY SYSTEM Lipid-rich foodfood- duodenum Lipid-rich duodenumpromotes promotessecretion secretion of CCK- contraction of the GB forcing bile into the duodenum Bile- emulsifying of of Bileemulsifying agent, agent,facilitates facilitateshydrolysis hydrolysis lipids by pancreatic lipases. reach duodenum (biliary tracttract IfIf bile bile fails failstoto reach duodenum (biliary obstruction), lipids are neither digested or absorbed resulting in the passage of loose foulsmelling fatty stools (steatorhhea)
FUNCTION OF THE BILIARY SYSTEM Fat-soluble vitamins Fat-soluble vitamins (A,D,E,K) (A,D,E,K) not not absorbed Lack of Lack of vit.K.vit.K.-inadequate inadequate prothrombine synthesis and hence defective clottingproblems if surgery is necessary
PATHOGENESIS OF GALLSTONE DISEASE Most gallstonesMost gallstones- cholesterol+bile cholesterol+bile pigment+calcium salts Small proportion Small proportion are are“pure” “pure” cholesterol stones Asia- most Asiamost gallstones-bile gallstones-bile pigment alone
PATHOGENESIS Mixed stonesMixed stones- combination combinationofof abnormalities of bile constituents, bile stasis and infection Pigment stonesPigment stones- excess excessbilirubin bilirubin secretion due to hemolytic disorders and infection
PATHOGENESIS Main factors: Main factors:
– Change Change in in concentration concentration of of bile bile constituents – Biliary stasis Biliary stasis – Infection Infection
PATHOGENESIS Bile salts maintain Bile salts and andlecithinlecithinmaintain cholesterol in a stable micelle formation An excess excess of relation An of cholesterol cholesterolinin relation to bile salts and lecithin is one of the main factors Cholesterol precipitation Cholesterol precipitation is is enhanced by biliary stasis and infection
EPIDEMIOLOGY OF GALLSTONES 10% of population probably 10% of the theadult adult population probably have gallstones Women are as often Women are affected affected4 times 4 times as often as men Pregnancy, obesity, Pregnancy, obesity,diabetis diabetisareare predisposing factors The typical said to be: The typical patient patientis is said to fair, be: fair, fat, fertile, female of fourty Poor fiber play a part Poor fiber diet dietmay may play a part
INVESTIGATIONS Exclude hematological Exclude hematological and andliver liver abnormalities Establish whether Establish whether gall gallstones stonesareare present in the GB or CBD Assess integrity duct andand Assess integrity ofofbile bile duct pancreatic duct
INVESTIGATIONS Hemolytic disorders: Hemolytic disorders: hereditary hereditary spherocytosis, thalassemia and sickle cell disease- pigment stones Liver function Liver function teststests-jaundice jaundice
Blood culturesBlood cultures- severe severeangiocholitis angiocholitis U&E for for pts vomiting U&E pts with withfrequent frequent vomiting or diarhhea
INVESTIGATIONS Ultrasound scanUltrasound scan- can canassess assess
– Presence Presence of of stones, stones, – Thickness Thickness of of GB GB wall wall (inflammation/fibrosis), – Duct Duct dilatation, dilatation, – Obstruction: Obstruction: stones, stones, tumor, tumor, parasites – Structure of liver, Structure of liver, pancreas, pancreas, spleen spleen
CT- ACUTE CHOLECYSTITIS
PLAIN ABDO X RAY
PLAIN ABDO X RAY
INVESTIGATIONS NON-JAUNDICED PATIENTS
Not necessary Not necessary preop. preop.investigations investigationsforfor duct stones IfIf in in doubtdoubt-peroperative peroperative cholangigraphy at cholecystectomy Cholangiography via Cholangiography via cystic cysticduct ductinto into the CBD- filling defects caused by stones or distorsion of the lower end of the CBD or obstruction
INVESTIGATIONS JAUNDICED PATIENTS History of History of transient transientjaundicejaundiceERCP or cholangio-RMN- plan the appropriate type of operation preoperatively Frank obstructive obstructive jaundiceFrank jaundicedistinguish between stone and cephalic pancreatic tumor
BIOCHEMICAL FEATURES OF OBSTRUCTIVE JAUNDICE
Conjugated hyperbilirubinemia Conjugated hyperbilirubinemia Elevation of Elevation of alkaline alkalinephosphatase phosphatase Minimal or or no thethe serum Minimal noelevation elevationof of serum transaminases Presence of thethe urine as as Presence of the thebilirubin bilirubinin in urine the conjugated bilirubin is water soluble Elevation in of cholesterol and and Elevation in the theserum serum of cholesterol bile acid levels
INVESTIGATIONS OBSTRUCTIVE JAUNDICE
USS of dilatation of the USS of the theabdomen: abdomen: dilatation of biliary the biliary ducts, stone lodged in the duct, cephalic pancreatic nodule, enlarged lymph nodes in the porta hepatis ERCP- diagnostic diagnostic and ERCPand therapeutic therapeuticprocedureprocedureendoscopic sphincterotomy releasing the stone, relieving the jaundice Percutaneous transhepatic Percutaneous transhepatic cholangiography cholangiography
ERCP
ERCPSPHYNCTEROTOMY STONE EXTRACTION
ERCP
CHOLANGIO MRI
CHRONIC CHOLECYSTITIS Intermittent cystic Intermittent cystic duct ductobstruction obstruction Typically, patients Typically, patients are areoverweight overweight female Chronic inflammationinflammation- thickened Chronic thickened and and shrunken GB Long history nausea, Long history of ofRH RHpain, pain, nausea, vomiting Pain exacerbated meals Pain exacerbated by byfatty fatty meals
CHRONIC CHOLECYSTITIS Symptoms are Symptoms are ill-defined: ill-defined:pain, pain, nausea, fatty food intolerance Signs: mild Signs: mild RH RHtenderness tenderness Differential dg Differential dg – – –
Peptic Peptic ulcer ulcer disease disease Urinary tract infection infection Urinary tract Irritable bowel disease disease Irritable bowel
CHRONIC CHOLECYSTITIS MANAGEMENT Cholecystectomy is Cholecystectomy is the thedefinitive definitive treatment
Classic or Classic or laparoscopic laparoscopic
CHRONIC CHOLECYSTITIS
CHRONIC CHOLECYSTITIS
CHRONIC CHOLECYSTITISLAPAROSCOPIC VIEW
LAPAROSCOPIC CHOLECYSTECTOMY
BILIARY COLIC Sudden and of of Sudden and complete completeobstruction obstruction the cystic duct by stone Severe pain, twists in in Severe pain, the thepatient patient twists agony until the pain resolves often precedes the the AA bout bout ofofvomiting vomiting often precedes end of the attack History of History of previous previoussimilar similarepisodes episodes Few positive local Few positive physical physicalfindingsfindingslocal tenderness, no fever
BILIARY COLIC MANAGEMENT Pain relief, abdomen Pain relief, USS USS ofofthethe abdomen Immediate cholecystectomy Immediate cholecystectomy oror put the patient on the waiting list Avoid fatty Avoid fatty foods foods
ACUTE CHOLECYSTITIS Surgical emergency Surgical emergency Biliary colic, Biliary colic, fever, fever,tachycardia tachycardia RH tenderness RH tenderness Palpable RH Palpable RH inflammatory inflammatorymass mass Clinical course Clinical course of ofacute acute cholecystitis is more prolonged than biliary colic
ACUTE CHOLECYSTITIS MANAGEMENT USS, CT: USS, CT: thickened thickened wall wall Oral intake Oral intake restricted restricted totofluids fluids IV fluids, antibiotics IV fluids, pain painkillers killersand and antibiotics Early cholecystectomy Early cholecystectomy For inflammatory For inflammatory massmassconservative treatment- elective cholecystectomy after 2-3 months
ACUTE CHOLECYSTITIS
GANGRENOUS CHOLECYSTITIS
Empyema of the gall bladder GB distended an an abscess of of GB distended with withpuspusabscess the GB Swinging pyrexia Swinging pyrexia Part of wall becomes necroticPart of the theGB GB wall becomes necroticperforation- biliary peritonitis Perforation is by by Perforation is usually usuallywalled walledoffoff omentum- localized abscess formation Sometimes- subphrenic Sometimessubphrenic abscess abscessoror generalized peritonitis Surgery without Surgery without delay delay
GALLSTONE ILEUS Uncommon complication Uncommon complication of ofchronic chronic cholecystitis GB becomes thethe GB becomes adherent adherenttoto duodenum, a stone ulcerating through the wall to form a fistula Fistula decompresses decompresses the Fistula the obstructed GB and allows stones to pass into the bowel and gas to enter the biliary tree
GALLSTONE ILEUS Diagnosis- plain gasgas intointo Diagnosisplain abdo abdoXrayXraythe biliary tree or fluid levels of the small bowel- biliary ileus radioopaque cancan IfIf obstructing obstructing stone stoneis is radioopaque be seen as an opacity in the RIF Operation is remove the the Operation is needed neededto to remove obstructing stone from the terminal ileum: enterotomy, extraction, enteroraphy
Biliary ileus Rigler’s triad offindings: findings: Rigler’s triad of small bowel obstruction; pneumobilia; and gallstone in right iliac fossa. Note the thethe biliary Note the gas gasin in biliary tree, and rounded opacity in the pelvis
CT of show air air CT of the theabdomen abdomen show in the gall bladder (red (red arrow) air in (blue (bluearrow) arrow) air in the theCBD CBD representing pneumobilia, the gallstone small the gallstone ininthe the small bowel lumen (yellow arrow) (yellow arrow) dilated and dilated and fluid-filled fluid-filledloops loops of small bowel from SBO (green arrow)
INTRA-OPERATIVE FINDING
TRANSVERSE ENTEROTOMY
STONE REMOVAL AND ENTERORAPHY
BILE DUCT STONES Nearly always Nearly always originated originatedininthethe GB and passed through the cystic duct Most stones enough to to Most stones are aresmall small enough pass out of the biliary system into the duodenum, resulting in biliary colic and transient jaundice
BILE DUCT STONES CBD is lower end end CBD is narrowest narrowestatatitsits lower and stones too large to pass out They tend at this pointpoint They tend totolodge lodge at this becomes AA stone stone here hereeither either becomes impacted- progressive jaundice or acts as a ball-valve- intermittent jaundice
BILE DUCT STONES Obstruction results Obstruction results in ingradual gradual dilatation of the biliary tree it does not not IfIf dilatation dilatation isislong longstanding standing it does regress even after removal of the obstruction- bile stasis- further stone formation Note that notnot distend whenwhen Note that GB GBdoes does distend there is an inflammatory fibrosis caused by gall stones
CLINICAL PRESENTATION BILE DUCT STONES
Obstructive jaundice Obstructive jaundice Asymptomatic duct Asymptomatic duct stones stones Acute pancreatitis Acute pancreatitis Ascending cholangitis Ascending cholangitis
OBSTRUCTIVE JAUNDICE Causes: Causes:
– Stones Stones in in the the CBD CBD – Carcinoma Carcinoma of of the the head head of ofthe the pancreas – Periampullary Periampullary tumors tumors – Benign Benign strictures strictures of of the the CBD CBD – Extrinsic bile duct duct obstruction obstruction Extrinsic bile – Intrahepatic Intrahepatic bile bile duct duct obstruction obstruction
ASYMPTOMATIC DUCT STONES Any patient stones maymay Any patient with withgall gall stones have duct stones Some surgeons Some surgeons do doat at cholecystectomy, routine cholangiography to exclude the presence of CBD stones Some surgeons if there are are Some surgeons do dothat that if there positive test of cholestasis or dilated CBD
Common bile duct stone (choledocholithiasis). The sensitivity of transabdominal ultrasonography for choledocholithiasis is approximately 75% in the presence of dilated ducts and 50% for nondilated ducts
Notice inside the catheter is a black and yellow striped guide wire, this guide wire stays in the common bile duct as the balloon catheter is manipulated. Notice the arrow pointing at a stone that was removed from the common bile duct by the balloon catheter. This stone will pass through the intestines and will be expelled.
ACUTE PANCREATITIS Stones near of Vater Stones near the theampulla ampulla of Vater may interfere with drainage of pancreatic enzymes onto the duodenum This induces into thethe This induces bile bilereflux reflux into Virsung duct- acute pancreatitis
ASCENDING CHOLANGITIS Bile stasis CBD duedue to chronic Bile stasis ininthe the CBD to chronic duct obstruction- predisposis to bacterial infection The infection to to The infection extends extendsproximally proximally involve the intrahepatic duct system Pain, swinging Pain, swinging pyrexia, pyrexia,jaundice jaundice Life-threatening conditionLife-threatening condition- acute acute suppurative cholangitis Urgent bile or or Urgent bile duct ductdrainage: drainage:surgery surgery endoscopic sphincterotomy
CARCINOMA OF THE GALL BLADDER Chronic iritation a long Chronic iritation by by stones stonesover over a long period is believed to predispose to adenocarcinoma of the gall bladder Rare condition, elderly Rare condition, found foundininthethe elderly Usually unexpected Usually unexpected finding findingatat cholecystectomy, incurable at the time of detection Presenting symptoms chronic Presenting symptoms similar similartoto chronic inflammatory gall bladder disease Jaundice may Jaundice may develop develop
MANAGEMENT OF GALLSTONE DISEASE Non-surgical treatment treatment Non-surgical
Surgical treatment Surgical treatment
NON-SURGICAL TREATMENT Chenodeoxycholic acid Chenodeoxycholic acid increases increases the bile salt pool and inhibits hepatic cholesterol secretion Long-term treatmentLong-term treatment- slow slow dissolution of cholesterol stones High-rate of High-rate of stone stonerecurrence recurrence Side-effects- diarrhea Side-effectsdiarrhea and andhepatic hepatic damage
SURGICAL TREATMENT Open or Open or laparoscopic laparoscopiccholecystectomy cholecystectomy Exploration of Exploration of CBDCBD-peroperative peroperative cholangiography Presence of stone Presence of CBD CBDstonestonestone extraction- T tube drainage (Kehr) T-tube cholangiography at at T-tube cholangiography after afterremoval removal 14-21 days postoperativelly
BILE DUCT DRAINAGE PROCEDURES Choledoco-duodenostomy Choledoco-duodenostomy Choledoco-jejunostomy Choledoco-jejunostomy Transduodenal sphyncteroplasty sphyncteroplasty Transduodenal Endoscopic sphyncterotomy Endoscopic sphyncterotomy
COMPLICATIONS OF BILIARY SURGERY Retained stone CBDendoscopic Retained stone ininthe the CBDendoscopic sphyncterotomy Biliary peritonitis leakageBiliary peritonitis due due totobile bile leakagelavage and drainage Bile duct Bile duct damagedamage-relaparotomyrelaparotomyreconstruction Hemorrhage- slipping Hemorrhageslipping knot knot from fromthe the stump of the cystic artery- hemostasis Ascending cholangitisAscending cholangitis- late latecomplication complication of choledocoduodenostomy
